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|Year : 2015
: 57 | Issue : 1 | Page
|Schizophrenia and gastroesophageal reflux symptoms
Elmas Kasap1, Ahmet Ayer2, Hümeyra Bozoğlan3, Cigdem Ozen3, Ilhan Eslek3, Hakan Yüceyar1
1 Celal Bayar University, Faculty of Medicine, Department of Gastroenterology, Manisa, Turkey
2 Manisa State Hospital for Mental Health and Neurological Disorders, Manisa, Turkey
3 Celal Bayar University, Faculty of Medicine, Department of Internal Medicine, Manisa, Turkey
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|Date of Web Publication||7-Jan-2015|
| Abstract|| |
Background: Psychological factors and psychiatric disorders play a role in a variety of gastrointestinal illnesses, including esophageal diseases.
Aim: The aim of the present study was to evaluate the frequency of gastroesophageal reflux disease symptoms in patients with schizophrenia in Turkey.
Patients and Methods: Ninety-eight patients with schizophrenia and one hundred control individuals were enrolled in the study, which was undertaken at the Manisa State Hospital for Mental Health and Neurological Disorders and Celal Bayar University Gastroenterology Department. Case and control subjects alike underwent 30-45 min oral interviews conducted by a designated study coordinator (E.K.). The coordinator gathered information about demographic characteristics, social habits, and a large variety of symptoms suggestive of reflux disease or other gastrointestinal conditions.
Results: In terms of reflux symptoms, cough was the only significant association in schizophrenic patients than controls. Heartburn and regurgitation were more frequent in schizophrenic patients who smoked than in controls who were smokers. However, the prevalence of reflux symptoms in cigarette smokers versus nonsmoker patients with schizophrenia was similar.
Heartburn and/or regurgitation occurred more frequently in patients with schizophrenic than controls with alcohol use.
Conclusions: Psychiatric disorders might indirectly affect esophageal physiology through increased consumption of alcohol and nicotine.
Keywords: Cough, heartburn, regurgitation, schizophrenia
|How to cite this article:|
Kasap E, Ayer A, Bozoğlan H, Ozen C, Eslek I, Yüceyar H. Schizophrenia and gastroesophageal reflux symptoms. Indian J Psychiatry 2015;57:73-7
| Introduction|| |
Gastroesophageal reflux disease (GERD) is the failure of the normal antireflux barrier to protect against frequent and abnormal amounts of gastroesophageal reflux.  GERD is common in the Western world, with about 10-20% of adults experiencing the problem weekly.  The typical manifestations of GERD are heartburn, regurgitation, and dysphagia.  Extraesophageal manifestations of GERD, particularly asthma, chronic cough, and laryngitis. ,
Psychological factors and psychiatric disorders such as depression and anxiety play a role in a variety of gastrointestinal illnesses, including esophageal diseases, and the mechanisms may influence the esophagus are numerous. 
Schizophrenia is one of the most severe mental illnesses, and it has significant health, economic, and social results.  Schizophrenia is a severe mental disorder that outcomes continue to be negatively.  Schizophrenia is one of the multiple systematic psychiatric conditions where important changes in the structure, physiology and chemistry of the brain occur. Developments in biochemistry, anatomy, and genetics have made it easier to pinpoint schizophrenia; nevertheless, the disease remains one where diagnosis is based on behavioral observations. ,
To our knowledge, studies of a potential link between schizophrenia and GERD symptoms have not yet been conducted. GERD can be evaluated using questionnaires and population-based research. 
Although causes of schizophrenia remain unknown, the disease has been commonly characterized by a symptomatic and neurocognitive perspective. 
The aim of the present study was to evaluate the frequency of GERD symptoms in patients with schizophrenia in Turkey.
| Materials and Methods|| |
Ninety-eight patients with schizophrenia and one hundred control individuals were enrolled in the study, which was undertaken at the Manisa State Hospital for Mental Health and Neurological Disorders and Celal Bayar University Gastroenterology Department. Our control group included patient without psychiatric and gastroenterological (GERD, irritable bowel syndrome, dyspepsia, constipation, diarrhea, epigastric pain) diagnosis and who were seeking treatment for other medical illnesses. We excluded from the schizophrenic population subjects with mental retardation, metabolic disease, or dementia and patients who were younger than 18 years and older than 65 years.
The patients were diagnosed with schizophrenia based on the Turkish version of the clinical interview for DSM-IV. This version utilizes the Structured Clinical Interview for DSM-Axis 1 Disorders and DSM-III-R, Structured Clinical Interview for DSM-Axis 2 Disorders Scale for the Assessment of Negative Symptoms (SANS), Scale for the Assessment of Positive Symptoms (SAPS), Calgary Depression Scale for Schizophrenia (CDSS), Udvalg for Kliniske Undersogelser (UKU) (Side Effect Scale), and the Brief Disability Questionnaire (BDQ). A description of the tests is presented below.
Scale for the Assessment of Negative Symptoms
This scale is evaluated on the basis of the results of an interview held with the patient, observations made during the interview and information obtained from people close to the patient (relatives, therapy team). The scale measures the level and distribution of and change in negative symptoms in schizophrenia. SANS includes five subscales and these subscales are affective flattening, alogia, apathy, anhedonia, and lack of attention. The scale uses a six-point Likert-type measurement. In assessing the validity and reliability of the Turkish version of SANS, no cut-off score has been calculated. ,,
Scale for the Assessment of Positive Symptoms
This scale is based on the same evaluation parameters as SANS. The aim of SAPS is to measure the level and distribution of and change in positive symptoms in schizophrenia. SAPS include 4 subscales and these subscales are hallucinations, delirium, weird behavior, and formal conception disorder. In common with SAPS, the scale uses a six-point Likert-type measurement. The Turkish version is not based on validity studies; the internal consistency of the scale is used as an indication. ,,
Calgary Depression Scale for Schizophrenia
This scale, developed by Addington et al., is based on the same assessment parameters as SANS and SAPS. In contrast to these two scales, CDSS evaluates depression and measures the level of and change in depressive symptoms. CDSS consists of nine articles and uses a four-point Likert-type measurement. The reliability and validity of the Turkish version have been established by Aydemir et al. ,,,
Udvalg for Kliniske Undersogelser (Side Effect Scale)
The UKU scale evaluates causal relationships resulting from side effects associated with the use of psychotropic drugs. The side effects are evaluated under various headings including psychological, neurological, and autonomic. The UKU is made up of 52 articles in total. The reliability of the Turkish version of the UKU has yet to be established. ,
Clinical Global Impressions Scale
This scale assesses the effect of depression on the patient and the response of the patient to treatment during clinical studies. CDI is divided into two categories defined as the impact of the disease and the general improvement provided by drug treatment. 
Brief Disability Questionnaire
The BDQ evaluates the patient's physical and social disability. A test-repeat, test reliability study was conducted in the Turkish version. The questionnaire contains two articles relating to daily jobs and the number of days spent in bed in the previous month. ,
Case and control subjects alike underwent 30-45 min oral interviews conducted by a designated study coordinator (E.K.). The coordinator gathered information about demographic characteristics, social habits, and a large variety of symptoms suggestive of reflux disease or other gastrointestinal conditions.
Heartburn was defined as a burning pain or discomfort behind the breastbone in the chest. Acid regurgitation was defined as a bitter or sour-tasting fluid entering the throat or mouth. Chronic cough is defined as a daily cough lasting for more than 8 weeks. Data were not collected on bloating, dyspepsia, or belching. As some psychiatric drugs may precipitate reflux symptoms following treatment were excluded from the study.  Cigarette use was ascertained as a history of cigarette smoking (yes or no) and for current smokers, the number of smoked per day. Alcohol use was defined in terms of the number of drinks on average per week during the past year. This study was performed in accordance with the Declaration of Helsinki, good clinical practice and applicable regulatory requirements. Celal Bayar University Institutional Review Board approved this clinical trial on August 2, 2009 with number 159. Informed written consent was obtained from each patient and controls.
The data were obtained using Statistical Package for the Social Sciences (SPSS Inc, Chicago,IL 60606-6412) version 12.0 for Windows 7. The Chi-square test and Fisher's exact test were used to determine demographic and social characteristics and disease symptoms among the case studies and controls. Age and lifetime consumption of alcohol or cigarettes were compared using the two tailed t-test. P <0.05 was defined as significant.
The odds ratios and their corresponding 95% confidence intervals served to describe the strength of (influence) associated with each individual predictor variable.
| Results|| |
The characteristics and reflux symptoms of the schizophrenic patients and the controls are summarized in [Table 1]. The two groups showed no differences in age, gender, and alcohol consumption (P > 0.05). Cigarette smoking was significantly more common among schizophrenic patients (P < 0.05). In terms of reflux symptoms, cough was the only significant association in schizophrenic patients than controls (P < 0.05).
|Table 1: The characteristics and reflux symptoms of the schizophrenic patients and the controls|
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Heartburn and regurgitation were more frequent in schizophrenic patients who smoked than in controls who were smokers [Table 2]. However, the prevalence of reflux symptoms in cigarette smokers versus nonsmoker patients with schizophrenia was similar [Table 3].
|Table 2: The reflux symptoms of the schizophrenic patients and the controls who smoked|
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|Table 3: The prevalence of reflux symptoms in cigarette smokers versus nonsmoker patients with schizophrenia|
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Heartburn and/or regurgitation occurred more frequently in patients with schizophrenic than controls with alcohol use [Table 4]. However, the prevalence of reflux symptoms in schizophrenic patients who used alcohol and who did not use alcohol was similar [Table 5].
|Table 4: The reflux symptoms of the schizophrenic patients and the controls who use alcohol|
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|Table 5: The prevalence of reflux symptoms in alcohol user versus who did not use alcohol patients with schizophrenia|
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| Discussion|| |
The relationship between psychiatric disorders and reflux disease has remained largely uninvestigated. The aim of the present study was, therefore, to evaluate the frequency of GERD symptoms in patients with schizophrenia in Turkey. To our knowledge this is the first study about GERD symptoms and schizophrenia. We know that some psychiatric treatment may precipitate gastroesophageal reflux symptoms and that it may have a reverse effect on esophageal motility.  In our study, reflux symptoms did not change after treatment, and treatment did not precipitate reflux symptoms. However, patients did experience constipation, diarrhea and bloating after treatment, although these were not included in the analysis in the present study.
In a study by Talley et al., 42% of psychiatric patients with a somatization disorders described typical reflux symptoms than control groups.  In our study, coughing was significantly more common among patients with schizophrenia than controls. Several studies have shown that heartburn, coughing, and dysphagia were more common in psychiatric patients than control groups. , The discordance with our findings may be attributed to patients in the schizophrenia group not responding to the question correctly. However, the patients were given numerous opportunities to obtain further clarification or additional explanation if needed. Moreover, all information was collected gathered using robust oral interviewing techniques, and suspicious responses were not accepted.
Previous studies of the association between cigarette use and reflux symptoms have also produced contradictory results, and the role of cigarette smoking in the pathogenesis of gastroesophageal reflux disease remains incompletely understood.  Laboratory studies have suggested that diet, cigarette smoking, alcohol intake, and body weight can stimulate gastroesophageal reflux. , Cigarette smoking and alcohol consumption may adversely affect the esophageal mucosa. , Smokers have chronically decreased lower esophageal sphincter (LES) pressure and increased rate of reflux events.  Smoking has also been associated with a series of mental disorders including schizophrenia, anxiety, and depression.  We found cigarette smoking was more common in patients with schizophrenia than in patients without the disease. Heartburn and regurgitation were more frequent in schizophrenic patients who smoked than in controls who were smokers. However, the prevalence of reflux symptoms in cigarette smokers vs. nonsmoker patients with schizophrenia was similar in our study.
Some recent studies suggest that alcohol ingestion decreases LES pressure and induced reflux symptoms. In a study by Ferdinandis et al., pyrosis and regurgitation were greater in patients with chronic alcoholism. Avidan et al. reported that heartburn was more common in alcohol-dependent patients with psychiatric disorders than healthy controls. , In our study, reflux symptoms (heartburn, regurgitation) were associated with alcohol use.
| Conclusion|| |
Psychiatric disorders might indirectly affect esophageal physiology through increased consumption of alcohol and nicotine. Thus, cigarette smoking combined with alcohol consumption in schizophrenia patients may increase reflux symptoms. Is there any other reason than smoking or alcohol? Especially, genetics or other environmental reasons in psychiatric disorders. We think these issues are worth investigation.
| Acknowledgment|| |
Special thanks to Dr. Ahmet Ayer of Manisa State Hospital for Mental Health and Neurological Disorders knowledge in relation to schizophrenic patients.
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Dr. Elmas Kasap
Department of Gastroenterology, Faculty of Medicine, Celal Bayar University, Manisa
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]